Summary At 0708 Pacific daylight time, the Pacific Coastal Airlines G-21A amphibian (registration C-GPCD, serial number B76) operating as a charter flight departed Port Hardy Airport, British Columbia, on a visual flight rules flight to Chamiss Bay, British Columbia. At 0849 and again at 0908, the flight follower attempted to contact the tugboat meeting the aircraft at Chamiss Bay by radiotelephone but was unsuccessful. At 0953, the flight follower reported the aircraft overdue to the Joint Rescue Coordination Centre in Victoria, British Columbia, and an aerial search was initiated. A search and rescue aircraft located the wreckage on a hillside near Alice Lake, approximately 14nautical miles from its departure point. A post-crash fire had ignited. The emergency locator transmitter had been destroyed in the crash and did not transmit. The accident happened at about 0722. Of the seven occupants, the pilot and four passengers were fatally injured, one passenger suffered serious injuries, while another suffered minor injures. The two survivors were evacuated from the accident site at approximately1610. Ce rapport est galement disponible en franais. Other Factual Information The accident flight was one of a series of charters to transport a logging company's personnel from Port Hardy, British Columbia, to a company facility at Chamiss Bay, British Columbia. Chamiss Bay is located approximately 37nautical miles (nm) south of Port Hardy, on the west coast of Vancouver Island, British Columbia. The flight was conducted under the auspices of Pacific Coastal Airlines' air taxi operations certificate issued under subpart703 of the Canadian Aviation Regulations (CARs). The flight was conducted under visual flight rules (VFR) by a single pilot. Port Hardy is Pacific Coastal Airlines' principal floatplane base. The company operates a TypeD operational control system under which operational control is delegated to the pilot-in-command of a flight.1 The Company Operations Manual (COM) requires that, before the flight, the pilot-in-command establish how the flight will be monitored and by whom.2 In this case, Pacific Coastal Airlines had a company flight watch facility at Port Hardy. The COM also requires the pilot-in-command to maintain communications with the flight watch facility,3 to monitor air traffic control and company frequencies, and to transmit position reports to Pacific Coastal Airlines' flight watch facility.4 Given the terrain and its impact on direct radio communications, it was not unusual for a flight to be out of contact with the flight watch facility for some time. Moreover, it was not unusual for company floatplane pilots to land and wait for improvements in weather or other conditions before proceeding to their destination without communicating this to the flight follower. The COM requires that, while out of range of company communications facilities, the pilot-in-command communicate any changes to the flight watch facility as soon as possible via an air traffic services unit or by telephone.5 The pilot was certified and qualified for the flight in accordance with existing regulations. He had been employed by the company for 1years. Experienced with this type of flight operation, he had accumulated 3998hours of flight time, including 500hours on the Grumman Goose (see Photo1). The pilot had received all required company training. As well, he had received pilot decision making and mountain flying training. The pilot had never been instrument rated; however, he had had basic instrument flight training and had successfully passed the written exam for an instrument rating in2005. This was the pilot's fifth day of work following two days off. He had flown 17hours in the last seven days and had been on duty for 1hour and 22minutes at the time of the accident. Nothing was found to suggest that he might have been fatigued. The Grumman G-21A Goose is an amphibious aircraft used by Pacific Coastal Airlines for passenger transportation along the Pacific coast. It is a piston-powered, propeller-driven, unpressurized, twin-engine aircraft with a total seating capacity of10. The aircraft was certified for flight in visual meteorological conditions. It was equipped with the standard configuration of flight instruments and a portable global positioning system (GPS). It also had a very high frequency (VHF) transceiver and a frequency modulation (FM) radio. Communications were, therefore, subject to line-of-sight limitations where range is dependent on height. Records indicate that the aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures. There are currently a number of non-line-of-sight communication technologies, some of which allow real-time tracking, available to operators: for example, high frequency (HF) transceivers, satellite telephones, or commercially available GPS-based tracking devices that provide internet-based messages to flight followers. The aircraft was not equipped with any of these. The graphical area forecast for the area of the accident effective at 0500,6 2hours and 22minutes before the accident, called for the following conditions: overcast clouds based at 800to 1200feet above sea level (asl) with tops at 3000feet asl, prevailing visibility greater than 6statute miles (sm), patchy visibilities from to 3sm in light drizzle and mist with ceilings from 300to 500feet above ground level(agl). The aviation routine weather report (METAR) for Port Hardy issued at 0700 was as follows: wind calm, visibility 20sm, overcast clouds at 1000feetagl, temperature 12C, dew point 10C, altimeter setting 30.18inches of mercury, remarks: 8oktas7 stratocumulus, sea-level pressure 1022hectopascals. Clouds were located on a mountain ridge to the south and southwest of the Port Hardy Airport. Before departure, the pilot contacted a representative of the logging company at Chamiss Bay to inquire about the weather conditions. The weather was reported as sunny skies and good visibility. A direct route from Port Hardy to Chamiss Bay requires flying over a ridge of mountains with heights above 2000feetasl and takes approximately 30minutes to complete (see the solid line in Figure1). In inclement weather, a number of passes are available to facilitate crossing the higher terrain near Alice Lake. Alternately, pilots can proceed south from Port Hardy towards Quatsino Sound, then west down the sound to the Pacific Ocean, then south along the coast to Chamiss Bay (see the dashed line in Figure1). With the exception of the area immediately south of the Port Hardy Airport, the terrain along this route is much lower; in fact, it is near sea level. However, this route takes 30minutes longer. In good weather conditions, pilots fly the direct route. In poor weather conditions, pilots typically use one of the passes or take the alternate route along the coast. Figure 1. Routes and accident site The pilot of the accident flight was familiar with the route from Port Hardy to Chamiss Bay. The pilot informed the flight watch facility that he would take the aircraft south out of Port Hardy towards Alice Lake, Victoria Lake, and onward to Chamiss Bay. If he could not make his way through, he would attempt to get to Quatsino Sound either by doubling back or by a pass either from Alice Lake or Victoria Lake. Estimated time of arrival at Chamiss Bay was between 0730 and 0800, depending on the route taken. The aircraft took off from Port Hardy at 0708 and flew south on the direct track to Chamiss Bay. The flight was conducted clear of cloud and below the overcast ceiling. Several minutes later, the aircraft passed to the west of Alice Lake and east of a northwest-southeast ridge. Spot heights in the surrounding area are in excess of 2000feet. As the aircraft approached the higher terrain, it began to climb gradually, and then more abruptly, to cross the cloud-covered ridge. Shortly thereafter, the aircraft's nose rose abruptly, the aircraft shuddered, the left wing dropped, and the aircraft descended steeply. The aircraft's wings then levelled and the nose began to rise. Before the aircraft's sink rate could be arrested, it struck the tree tops and fell to the ground beneath a dense canopy of foliage. The two passengers seated rearmost in the aircraft exited through a tear in the fuselage aft of the left rear exit. One of the survivors had difficulty releasing his seat-belt. It is unknown whether this was as a result of the seat-belt installation, injuries sustained during impact, or both. The fuel tanks were breached by the impact forces, spilling a considerable quantity of fuel. Soon after, electrical arcing from exposed wires ignited an intense fire. Between 0826 and 0953, the flight follower at Port Hardy made several attempts to ascertain the aircraft's position. These included unsuccessful attempts to contact the pilot directly on the radio, two failed attempts by radiotelephone to contact the tugboat that was meeting the aircraft, and unsuccessful attempts by other company aircraft to contact the pilot on 122.2MHz and the company frequency. At 0929, another Pacific Coastal Airlines G-21A aircraft was dispatched to trace the route of the accident flight and to attempt to contact and/or locate the aircraft. The second aircraft flew the entire route to destination but did not locate the aircraft. At 0953, the flight follower advised the Victoria Joint Rescue Coordination Centre that the aircraft had not arrived at ChamissBay. A Canadian Forces Buffalo aircraft and a Cormorant helicopter were dispatched from Comox, British Columbia, to search for the missing aircraft. Retracing the aircraft's presumed track, search and rescue (SAR) aircraft flew in the vicinity of the accident site several times. However, the emergency locator transmitter (ELT) had been destroyed in the crash and was not operating; furthermore, the downed aircraft was hidden in dense forest. As a result, the SAR aircraft were initially unable to locate the wreckage. The less seriously injured survivor used his cellular telephone to call for help with limited success before the battery charge became insufficient for further voice transmissions. He later succeeded in completing several text messages, advising that he could hear the search aircraft at times. The missing aircraft was located at 1610and SAR technicians were lowered from the helicopter to the site. The two survivors were evacuated approximately 8hours and 48minutes after the accident occurred. The wreckage was found on the east face of a steep, densely wooded slope, at an elevation of 1860feetasl, with trees reaching to 160feet. Except for the engines, tail section, left wing-tip, and sponson, most of the aircraft was destroyed. Because the GPS had been consumed by fire, its data could not be retrieved. Both engines and propellers were shipped to the TSB regional facility for further examination. Because of substantial differences in damage between the two propellers, TSB investigators carried out a propeller teardown, assisted by a representative of the propeller manufacturer. The right propeller showed severe impact damage. The left propeller did not show evidence of a significant impact. It was concluded that both propellers were rotating with power and were not feathered at time of impact. No discrepancies were noted that would have precluded normal operation, and all damage was consistent with impact damage. It was concluded that the difference in damage to the two propellers was due to different object strikes during impact, rather than a substantial difference in power output. The engines were disassembled to the extent necessary to determine that no major malfunctions had occurred. The aircraft was not designed, and therefore not equipped, with a stall warning system. The company provided stall recovery training during both the pilot's initial and recurrent type training in March2007 and2008, respectively. When practising stalls on the G-21A aircraft, pilots were trained to initiate recovery at the very first indication of an approaching stall, which is a buffet. This is emphasized during training because, when the full stall angle is reached, a significant loss of altitude occurs before full recovery can be made.